Single coronary arteries: two cases with distinct and previously undescribed angiographic patterns.

Single coronary artery is a rare congenital anomaly, sometimes associated with myocardial ischemia. We present the clinical and angiographic features of two symptomatic patients with documented myocardial ischemia and with distinct and previously undescribed patterns of single right coronary arteries. These cases are new variants of the types R-I and R-II-A, in which the most probable mechanisms of ischemia are the insufficient blood supply, due to the long trajectories of the single arteries and the presence of underdeveloped vessels. Also, our second case presented with a fistulae from the LCX to the left ventricle, which is another determinant of myocardial ischemia.

[Mitral catheter-balloon valvuloplasty in surgical high risk patients]. / Valvoplastia mitral por cateter-balão em pacientes de alto risco operatório.

PURPOSE: To evaluate percutaneous mitral balloon valvuloplasty (PMBV) in surgical high risk patients. METHODS: Twenty (12%) patients out of 172 submitted to a PMBV were considered high surgical risk cases; 17 (85%) were women and mean age was 43 (18-69). Thirteen (65%) were in acute pulmonary edema (3 were pregnant, 2 had previous cerebrovascular event, 1 had pulmonary thromboembolism and other had chronic renal failure), and 7 (35%) were in functional class (CF) III (2 had coronary artery disease, 2 severe obesity, 1 pulmonary neoplasia, 1 cardiac cachexia and one with previous cerebrovascular event). All patients underwent PMBV through transseptal technique. Double balloon was used in 10 (50%) patients; Inoue balloon in 5 (25%), mono-foil in 3 (15%) and bi-foil in 2 (10%). RESULTS: Seventeen (85%) obtained success and 2 (10%) had clinical improvement. The hemodynamic results pre versus post-PMBV showed: left atrium pressure (LAP) mmHg 28.2 +/- 10.0 x 15.2 +/- 9.2 (n = 20) (p < 0.001), mitral medium gradient (G) mmHg 21.2 +/- 10.7 x 10.7 +/- 6.7 (n = 18) (p < 0.001), mitral valve area (MVA) cm2 0.73 +/- 0.3 x 1.73 +/- 0.6 (n = 11) (p < 0.001), pulmonary artery pressure mmHg 52.0 +/- 18.2 x 40.1 +/- 14.7 (n = 18) (p < 0.001) and cardiac index L/min/m2 2.1 +/- 0.4 x 2.5 +/- 0.6 (n = 14) (p < 0.001). Comparative echocardiography results pre, post and 6 months after PMBV showed: MVA 1.06 +/- 0.39 x 1.92 +/- 0.51 x 1.65 +/- 0.5 and G 13.8 +/- 4.7 x 7.3 +/- 3.6 x 7.3 +/- 4.4. There were two immediate deaths (pulmonary thromboembolism and multiple organs failure) and other after hospital discharge. The complications were: 2 (10%) patients with neurological complications, 1 (5%) atrial septal defect and other right atrium perforation (5%). CONCLUSION: PMBV offers an alternative to surgical treatment in high risk surgical patients and the results are maintained in the 6 month follow-up.

[Mitral stenosis correction by double catheter-balloon valvuloplasty technique]. / Correção de estenose mitral através de valvoplastia por técnica de duplo cateter-balão.

PURPOSE: To evaluate long-term efficacy of double balloon percutaneous mitral valvuloplasty technique (PMV2B). METHODS: Sixty-eight patients (76% female), mean-age 32 (15-69) years who had been submitted to PMV2B, that completed clinical and echodopplercardiographic one year follow-up (PO12M). Admission criteria were: exertional dyspnoea, no thromboembolism antecedent up to three months before the procedure, absence of other cardiac disease requiring correction, an admissible echodopplercardiographic score, absence of intracavitary thrombus and mitral regurgitation absent or minor. RESULTS: The patients were divided in two groups: group A of 7 (11%) patients that have a cardiac event in this period, and group B of 61 patients that completed the follow-up without a cardiac event. In group A three patients have had a severe mitral regurgitation, one case was unsuccessful and other one had a re-stenosis. There were two deaths, not related to the intervention. In group B, haemodynamic results before and immediately after PMV2B (POI) showed a significant improvement, except in relation to cardiac index. There was an increase in the grade of mitral regurgitation in 17 (28%) patients and in two cases this regurgitation became moderate. The mitral valvar area (MVA) variation between PRE x POI x PO12M presented, comparing MVA between POI and PO12M, a significant reduction. Two (3%) patients with a reduction greater than 50% of the initial increase, 33 (54%) between 10 and 50% and 26 (42%) less that 10% remained in functional class I/II. CONCLUSION: PMV2B is an attractive treatment to select symptomatic mitral stenosis patients, with a low incidence of complications, symptomatic effective improvement that was maintained in one year follow-up, although there was a reduction in MVA.

[Treatment using balloon catheterization of pulmonary valve stenosis]. / Tratamento por cateter-balão da estenose pulmonar valvar.

From October 84 to September 88 we performed pulmonary valvuloplasty with balloon catheter (PVBC) in 90 patients (pt) with pulmonary valve stenosis (PVS). The patients were divided in 3 groups (Gr) by their ages: group I (Gr. I) 7 pt (8%) aged 4 days to 11 months, Gr. II 66 pt (73%) aged 1 year to 12 years and Gr. III 17 pt aged 13 to 34 years. This study consists of clinical and echocardiographic evaluation adopting the following parameters of indication: a) transvalvar pulmonary gradient (G); b) absence of dysplasia or hypoplasia of the pulmonary annulus. There were associated lesions which were found in each group: Gr. I atrial septal defect (ASD) in 2 pt and tricuspid insufficiency (TI) in 1 pt, in Gr. II supra valvar stenosis (SVS) in 1 pt and patent arterial ductus (PAD) in 1 pt and in the Gr. III (ASD) in 1 pt. The results after pulmonary valvuloplasty with balloon catheter (PVBC) were: (Gr.I) in 5 pt the G were reduced below 50 mmHg and the average of right ventricular systolic pressure (RVSP) changed from 92 to 62 mmHg and the average of G from 76 to 44 mmHg. One of these pt was submitted to surgery 1 month after the procedure and 2 developed restenosis in 2 and 3 years respectively, being submitted to another dilatation with good results. The 2 pt in which the procedure was not effective were submitted to surgery. In the second group the PVBC was effective in 61 pt (92%) showing the RVSP changed from 118 to 64 mmHg and G changed from 86 to 23 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative study between inoue single balloon and double balloon in percutaneous mitral valvuloplasty. Immediate results and after 1 year follow-up]. / Estudo comparativo entre balão único de inoue e duplo balão na valvoplastia mitral percutânea. Resultados imediatos e após seguimento de um ano.

PURPOSE: To compare early and 12 months results of mitral stenosis (MS) correction by percutaneous balloon valvuloplasty (PMBV) using Inoue's single-balloon or double balloon techniques. METHODS: We submitted 139 consecutive patients to PMBV using Inoue single-balloon (n = 56, GI) or the double balloon technique (n = 83, GII). The two groups were similar, in: age, sex, functional class (FC), echocardiographic (ECHO) score, mitral valve area (MVA), and gradient (G) or presence of regurgitation. Clinical and ECHO data were compared before (PRE), immediately after (POI) and one year following the procedure (PO12M). RESULTS: PMBV was successfully performed in 53 (95%) patients of GI and in 79 (96%) of GII. Statistical analyses showed that the groups were similar at POI but different at PO12M (p < 0.002). ECHO immediately after PMBV showed that: MVA increased from 0.99 +/- 0.23 to 2.01 +/- 0.44cm2 (p < 0.001) in GI and from 0.94 +/- 0.23 to 2.09 +/- 0.35cm2 (p < 0.001) in GII and G decreased from 11.58 +/- 5.02 to 5.16 +/- 2.23mmHg (p < 0.001) in GI and from 12.48 +/- 4.89 to 5.96 +/- 3.21mmHg (p < 0.001) in GII. After one year 36 (64%) patients in GI and 62 (74%) in GII underwent an ECHO study. A comparison between immediate and one year follow-up results showed that MVA decreased from 2.01 +/- 0.4 to 2.00 +/- 0.3cm2 (NS) in GI and from 2.09 +/- 0.3 to 1.74 +/- 0.4cm2 (p < 0.001) in GII and G decreased from 5.16 +/- 2.2 to 5.50 +/- 2.9mmHg (NS) in GI and from 5.96 +/- 3.2 to 8.61 +/- 4.8mmHg (p < 0.001) in GII. There was therefore a sustained improvement of MVA and G after one year in GI and a significant decrease in MVA and G in GII. The FC after one year was similar and satisfactory in both groups. CONCLUSION: Both techniques are equally effective in relieving MS immediately after PMBV, but after one year, despite similar FC, Inoue-balloon technique seems to be superior to maintain MVA and G.

[Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis]. / Avaliação comparative entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral.

PURPOSE: To compare immediate and late (12 months) follow-up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2 +/- 5.8 to 5.80 +/- 2.7 (p < 0.001) in commissurotomy group (CG) and from 11.7 +/- 6.1 to 5.0 +/- 2.4 (p < 0.001) in the balloon valvuloplasty group (VG). Mitral valve are (cm2) increased from 0.98 +/- 0.21 to 2.52 +/- 0.46 in CG and from 1.05 +/- 0.25 to 2.18 +/- 0.40 in VG (p < 0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however, there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

[Transluminal angioplasty of aortopulmonary anastomosis by the Jatene surgical technique. Report of 2 cases]. / Angioplastia transluminal da anastomose aorto-pulmonar da cirurgia de Jatene. Aplicação em dois casos.

Two patients with transposition of the great arteries submitted to Jatene surgery at ages of 6 days and 6 months respectively, presented in the postoperative period stenosis of the aorto-pulmonary anastomosis. The diagnosis was made three and six years after the surgery. In both patients successful percutaneous transluminal angioplasty (PTA) was performed, respectively six months and immediately after the diagnosis. Pressure gradients decreased from 83 mmHg to 24 mmHg in the first case, and from 76 mmHg to 13 mmHg in the other case, with clear improvement of the angiographic image. Complications of the procedure did not occur in any case. This application for PTA was not previously reported and should be considered as an alternative to the surgical correction of the "new" pulmonary trunk stenosis in the Jatene surgery.

Intracoronary brachytherapy in the treatment of in-stent restenosis. Initial experience in Brazil.

Intracoronary brachytherapy using beta or gamma radiation is currently the most efficient type of therapy for preventing the recurrence of coronary in-stent restenosis. Its implementation depends on the interaction among interventionists, radiotherapists, and physicists to assure the safety and quality of the method. The authors report the pioneering experience in Brazil of the treatment of 2 patients with coronary in-stent restenosis, in whom beta radiation was used as part of the international multicenter randomized PREVENT study (Proliferation REduction with Vascular ENergy Trial). The procedures were performed rapidly and did not require significant modifications in the traditional techniques used for conventional angioplasty. Alteration in the radiological protection devices of the hemodynamic laboratory were also not required, showing that intracoronary brachytherapy using beta radiation can be incorporated into the interventional tools of cardiology in our environment.

[Surgical intervention in patients undergoing a procedure for mitral valvoplasty by balloon catheterization]. / Intervenção cirúrgica em pacientes submetidos a procedimento para valvoplastia mitral por cateter-balão.

PURPOSE: To study the characteristics of patients undergoing catheter-balloon mitral valvoplasty (CBVM) procedure who needed surgical intervention after CBMV. PATIENTS AND METHODS: One hundred and five patients submitted a CBMV were divided in to Group I (GI) of eighteen surgical patients and Group II (GII) of eighty-seven non-surgical patients. The following parameters were analyzed. 1) age; 2) sex; 3) mitral valve area (MVA) and mean transvalvular gradient (G) by echodopplercardiography (2D); 4) Character of CBMV; 6) Relation of time between CBMV and Surgery with surgical indication; 7) Surgical findings; 8) Surgical procedure and 9) Post-operative evolution. RESULTS: Mean age of 34 (17-56) years old in GI and 33 (15-69) years old in GII; 2) Similar distribution of men and women in GI and GII; 3) Similar MVA and G in GI and GII; 4) 100% of elective character in GI and 94% in GII; 5) Transseptal via in 17 (94%) of GI and 87 (83%) of GII, retrograde arterial via in 1 (5.5%) of GI and in another (1%) of GII; 6) immediate: cardiac tamponade (28%); until 30 days: unsuccessful CBMV (39%); mitral insufficiency (MI) post-CBMV (11%), cardiac tamponade (5.5%), between 30 and 60 days: MI post-CBMV (22%), Mitral restenosis post-CBVM (5.5%); 7) Mitral stenosis (72%), MI post-CBVM (22%), hemopericardium (6%); 8) Mitral Commissurotomy (7), Mitral bioprosthesis implant (5), Commissurotomy plus Atrioseptoplasty (1), Mitral plasty (1), Pericardium drainage (1); 9) One (5.5%) death in immediate post-operative of the MI correction, 17 (94%) in functional class I/II (NYHA) 14.3 (8-27) months after surgery. CONCLUSION: Age, Sex, VMA G and Urgency character were not discriminative factors in the formation of GI and GII. The procedures for CBVM didn't interfere with post-operative prognosis.

[Prevalence of residual shunt after closure of patent ductus arteriosus with Rashkind umbrellas]. / Prevalência do shunt residual após fechamento de canal arterial persistente com umbrellas de Rashkind.

PURPOSE: To determine the prevalence of residual left-to-right shunt in patients submitted to closure of patent ductus arteriosus with use of Rashkind double-disc ductal occluding device, analyzing predictive factors that determine short and long-term prevalence of residual shunt. METHODS: Thirteen patients were submitted to percutaneous closure of patent ductus arteriosus with use of Rashkind double-disc device. Ten patients were male with mean age of 5.7 years. A 12mm diameter device was used in 7 cases and a 17mm device in the remaining six patients. All patients had clinical, radiological and echocardiographic follow up, after 24h, 1 month, 6 months and one year after the procedure. Morphology and length of the ductus arteriosus and the presence of residual shunt after 15 min, 24h and one year after the procedure, were correlated. RESULTS: In one case, embolization of the device to the pulmonary artery determined the in success of the procedure. Residual shunt was present in 75% of the patients after 15 min of the procedure, in 33.3% after 24h, in 25% after 1 month and 6 months and in 16.6% after 1 year. The most important and isolated predictive factor leading to a high prevalence of residual shunt after 24h and after 1 year of the procedure was the presence of ductus arteriosus diameter > or = 4.5mm at the site of its insertion in the pulmonary artery. CONCLUSION: Prevalence of residual left-to-right shunt decreases over the time, with a low incidence after one year follow-up. A higher incidence of residual shunt at 24h and 1 year after the procedure occurred in the cases where the diameter of the ductus arteriosus was > or = 4.5mm, at the site of its insertion in the pulmonary artery.

[Do mitral valve components have the same predictive value in percutaneous balloon mitral valvuloplasty? Doppler echocardiography study]. / São os componentes do aparelho valvar mitral de mesmo valor preditivo na valvoplastia mitral por cateter balão? Estudo ecodopplercardiográfico.

PURPOSE: To evaluate the predictive value of mitral valve components in percutaneous balloon mitral valvuloplasty (PBMV). METHODS: 53 patients undergoing PBMV were submitted to an echocardiographic analysis of mitral valve in order to note mobility, thickness, calcification of leaflets and subvalvar apparatus (SV). Mitral valve area (VA) before and after PBMV was obtained using continuous wave Doppler. Patients were divided in group 1 (VA enhance inferior to 50%) and 2 (VA enhance equal or superior to 50%) and subgroups A (VA post PBMV inferior to 1.5 sqcm) and B (VA post PBMV equal or superior to 1.5 sqcm). Correlations between the score of each component of mitral valve and the results were established. RESULTS: Concerning to the total score, there was no significant difference between the groups and subgroups. Differences were significant when SV was analysed separately (p less than or equal to 0.001). VA average in patients with SV compromising grade 3 (1.28 +/- 0.26 sqcm) was inferior to those with grade 1 or 2 (p less than or equal to 0.001). CONCLUSION: SV has a higher predictive value in the success of PBMV.

Persistence of hypoplastic and recoarcted fifth aortic arch associated with type A aortic arch interruption: surgical and balloon angioplasty results in an infant.

A rare aortic malformation, the persistence of the fifth aortic arch (PFAA) associated with coarctation of the aorta, is reported in a 3-month-old male infant who underwent an emergency surgical intervention at 10 days of life, to relieve a severe aortic coarctation by pericardial patch technique. A successful balloon angioplasty was performed 2 months later eliminating a recoarctation. The gradient fell from 77 mmHg to 0, but a definitive surgical intervention for recoarctation was necessary 14 months after angioplasty.